This document discusses diverticular disease, including its definition, risk factors, pathophysiology, clinical features, investigations, classifications of complications, and management. Diverticular disease involves out-pouchings in the colon wall and is common in older individuals in western countries. Computed tomography is the gold standard for diagnosing complications like diverticulitis. Treatment depends on the severity and includes antibiotics, percutaneous drainage, surgery, and lifestyle modifications to reduce risk factors.

1. DIVERTICULAR DISEASE
Dr H.M Malinga gunarathne
Surgery registar
Ward 11/12
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2. Objectives
• Introduction
• Aetiology and risk factors
• Pathophysiology
• Clinical features
• Investigations
• Management
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3. Introduction
• Definition -Out pouching of the wall of a hllow viscus through a defect.
• Classification
Congental – Meckel’s diverticulua
Acquired – colonic diverticula
True –contain all layers of viscus (Meckel’s diverticulua)
false- no all layers/ no muscle layer(sigmoid diverticulua)
• Epidermiology
Before 30 years -rare disease
After 40 years - common
After 60 years – found in one third of individuals
After 70 years – incident rate is >70%
Common in western
Common in sigmoid and left colon than right colon
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4. Risk factors
• Old age
• Western world diet with low fibers
• Obesity
• Smoking
• NSAID
• Steroids
• Male > female
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5. Pathophysiology
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DIVERTICULAR
DISEASE
Alterd
collagen
structure
Prolonged
colonic
transit
time
High intra
luminal
pressure

6. Complications
• Luminal obstruction of diverticulum > increase pressure in diverticulum >
impaired venous drainage > Thrombosis > impaires arterial blood supply >
ischemia & infarction with colonization
Diverticulitis
Abscess
Peritonitis
Intestinal obstruction
Haemorrhage
Fistula formation
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7. Classification of complications
• Systems
1. Hinchey/ modified hinchey
2. Hansen/Stock
3. Sartelli
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8. Modified hinchey classification
• Stage o - Mild clinical diverticulitis
• Stage I - Pericolic abscess
Ia Confined pericolic inflammation
Ib Confined small (<5 cm) pericolic abscess
• Stage II - Pelvic, distant intra-abdominal, or retroperitoneal abscess
• Stage III- Generalised purulent peritonitis
• Stage IV - Generalised faecal peritonitis
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9. Clinical features
• 75% asymptomatic
• features of simple disease
LIF pain, distention, flatulence and a sensation of heaviness in the
lower abdomen, change in bowel habits
• features of complications
PR bleeding, features of peritonitis, pyuria etc
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10. Investigations
• CECT –GOLD standard
excellent sensitivity and specificity for identifying bowel wall thickening, abscess
formation and extra- luminal disease
• Adjuncts
1. USS
2. MRI
3. Colonoscopy- in acute stage has a risk of perforation
4. Barium enema
5. Plane X ray - demonstrate a pneumoperitoneum
6. Others –FBC,CRP,serum lactate
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11. Management
Supportive management
• initial resuscitation
• Analgesics
• Rest the bowel in acute stage
• High fiber diet & bulk forming laxatives
• Antispasmodics
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12. Specific management
Hinchey 0-1a(well patients)
• IV antibiotics with anerobic
cover
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Hinchey 1b-IV (unwell patients)
• IV antibiotics with anerobic
cover
• Guided percutaneous
drainage
• Laparoscopic lavage
• Hartmann’s procedure
• Resection(sigmoid) &
Primamry anastomosis

13. • Antibiotics for uncomplicated diverticulitis?
As the aetiology is unknown, diverticulitis may be an inflammatory
condition rather than an infective/ bacterial problem
AVOD - antibiotics versus no antibiotics for uncomplicated
diverticulitis and found no significant difference in complication rate,
length of stay or recurrent diverticulitis
DIABOLO -This study is currently recruiting patients
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14. laparoscopic lavage vs resection
• trials comparing laparoscopic lavage with primary resection in unwell
patients
1. SCAND – no advantage in laparoscopic procedure
2. DILALA – more benefits in laparoscopic procedure
3. LADIES – abandoned
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15. Followup
• Elective surgery
Recurrent diverticulitis
Patients with fistula
• Followup colonoscopy
Beacause the risk of developing carcinoma in complicated cases
• Risk factor modification
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17. Refferences
• Bailey & Love’s SHORT PRACTICE of SURGERY
• Companion to Specialist Surgical Practice series
• Surgery international journals
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19. summary
• Disease of aging
• The aetiology remains unknown but genetics, geographical location,
ethnicity and lifestyle factors (smoking and obesity) play a role.
• Computed tomography is the gold standard for investigating
diverticular disease.
• Complications-Diverticulitis ,Abscess ,Peritonitis,Intestinal
obstruction,Haemorrhage ,Fistula formation
• Antibiotics may not be necessary in the treatment of mild attacks.
• Surgical management depend on patient.
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